446 Abstracts

, GUN OWNERSHIP AND FIREARM-RELATEDDEATHS. Bangalore S, Messerli FH. Am J Med 2013;126:873-6.

Gun ownership has remained a topic of ardent debate, partic-ularly in the wake of a series of national tragedies relating to theuse of firearms. The authors of this study sought to examine apossible relationship between gun ownership and firearm-related deaths across 27 developed countries. Data on gunownership were attained from the Small Arms Survey of2007, and data on firearm-related deaths were acquired fromthe European detailed mortality database of the World HealthOrganization, as well as the National Center for Health Statis-tics. Data on the crime rate were attained from the UnitedNations Survey of Crime Trends. The authors found a statisti-cally significant positive correlation between gun ownershipand firearm-related death, with r = 0.80 and p < 0.0001. Theyalso found a positive correlation between mental illness burdenand firearm-related deaths, with r = 0.52 and p of 0.005. In alinear regression model, per capita gun ownership was a signif-icant predictor of firearm-related death andmental illness was ofborderline significance. The data demonstrate a strong positivecorrelation between per capita gun ownership and firearm-related deaths. The linear regression further demonstrates thiscorrelation. Although the authors note that correlation doesnot necessarily imply causation, they propose that high crimerates could promote widespread anxiety, leading to an increasein gun ownership and thus, a higher rate of firearm-relateddeaths.

[Ben Murphy, MD

Denver Health Medical Center, Denver, CO]

Comments: This study provides strong evidence against theview that gun ownership makes a country safer, showing thatit actually increases firearm-related mortality. Although a causallink between firearm ownership and firearm-related mortality islogical, the authors note that a direct causal link cannot be madefrom their data. In regards to the association of mental healthillness with firearm-related mortality, the authors were limitedto looking at disability-adjusted life-year rates due to majordepressive disorder, but not other mental health conditions.

, EPIDEMIOLOGY OF BACTEREMIA IN FEBRILEINFANTS IN THE UNITED STATES. Biondi E, Evans R,Mischler M, et al. Pediatrics 2013;132;990–6.

This retrospective review evaluated the epidemiology ofbacteremia in febrile infants < 90 days old at six different hos-pital sites across the country. The study included only healthyinfants without complex comorbidities who were admitted tothe general pediatrics ward. Infants admitted to the intensivecare unit were excluded. The study identified 181 cases ofbacteremia that met inclusion criteria. The most common path-ogen was Escherichia coli (42%). Of these cases, 91% werefound to have concurrent E. coli urinary tract infection. Thenext most common cause of bacteremia was group B Strepto-cocci (GBS), which was causative in 23% of cases. Twenty-seven percent of these infants were found to have concurrentGBS meningitis. Only 6% of cases were found to be caused

by Streptococcus pneumoniae, and these were mostly in olderinfants with a median age of 65 days. Five percent of caseswere due to Staphylococcus aureus and this was most commonin cases with concomitant skin and soft tissue infection. Nocases of Listeria monocytogenes were identified in the studypopulation.

[Avery MacKenzie, MD

Denver Health Medical Center, Denver, CO]

Comment: Current recommendations for empiric antibioticcoverage for febrile infants with concern for bacteremia includeampicillin for coverage of L. Monocytogenes and Enterococcussp. This study identified an incredibly low incidence of both ofthese conditions, and suggested that in the future, empiricmonotherapy with a third-generation cephalosporin may beadequate treatment. However, the study population was incred-ibly limited—those included were well enough appearing to beadmitted to the floor, but sick enough to not be discharged home.Overall, of the 2901 positive blood cultures identified, only 181individual cultures were included in the analysis, severelylimiting the generalizability of the results.

, AVOIDABLE ANTIBIOTIC EXPOSURE FOR UN-COMPLICATED SKIN AND SOFT TISSUE INFEC-TIONS IN THE AMBULATORY CARE SETTING. HurleyHJ, Knepper BC, Price CS, et al. Am J Med 2013;126:1099–106.

Uncomplicated skin and soft tissue infections are frequentindications for outpatient encounters and exceed 14 millionpatient visits a year! The vast majority of these result in anantibiotic prescription. This retrospective cohort study evalu-ated patients presenting to ambulatory care settings at one hos-pital who were given the diagnosis of cellulitis, abscess, and(nonsurgical) wound infections. The authors assessed the fre-quency of ‘‘avoidable antibiotic exposure’’ as defined by theInfectious Disease Society of America (IDSA) guidelines. Pri-mary end points included use of antibiotics with broad-spec-trum Gram-negative activity, combination antibiotic therapy,and treatment for 10 or more days. Secondary end pointsincluded cases of cellulitis with an antibiotic against methi-cillin-resistant Staphylococcus aureus (MRSA) prescribed,and adequately drained abscesses where an antibiotic was pre-scribed. Overall, approximately 300 cases were included forevaluation. Avoidable antibiotic exposure occurred in 46% ofcases. Treatment for 10 or more days occurred in 42% of casesand combination therapy was prescribed in 12%. Antibioticprescription after abscess drainage was given in 80% of cases.Antibiotics against MRSA were prescribed in 61% of cases ofcellulitis. Treatment failure rates were not different betweencases involving avoidable antibiotic exposure and all others.Utilizing the most restrictive treatment model (no antibioticsfor abscesses meeting criteria for drainage alone and 5-daycourse of single antibiotics for all other cases) offered by theIDSA guidelines would have reduced antibiotic days in thisstudy by up to 55%.

[Avery MacKenzie, MD

Denver Health Medical Center, Denver, CO]

The Journal of Emergency Medicine 447

Comments: By understanding the microbiology of skinand soft tissue infections and targeting the most common bacte-ria—b-hemolytic strep in cellulitis and MRSA in abscess, pro-viders can more thoughtfully make antibiotic decisions. Thesedata demonstrate that this is currently not being done well, butalso represent a very tangibleway to change prescribing practicepatterns in the emergency department. This practice could haveimportant benefits for patients by decreasing side effects andcosts of unnecessary medications. Limiting antibiotic prescrip-tions also has broader societal effects by helping to stave off thegrowth of antibiotic-resistant organisms.

, EFFECTOFCOMMUNICATION SKILLS TRAININGFOR RESIDENTS AND NURSE PRACTITIONERS ONQUALITY OF COMMUNICATION WITH PATIENTSWITH SERIOUS ILLNESS: A RANDOMIZED TRIAL.Curtis JR, Back AL, Kross, EK, et al. JAMA 2013;310:2271–81.

Effective communication with critically ill patients andtheir families is an important but frequently difficult skill forphysicians. Previous observational studies suggest that com-munication about end-of-life care is associated with bothincreased ‘‘quality of life’’ and ‘‘quality of dying,’’ and thatcommunication interventions for providers can further im-prove these patient-reported outcomes. This study randomized472 new providers to receive eight sessions of simulation-based communication training or usual education and assessedthe effect on patient and families’ reported quality of commu-nication (QOC) and quality of end-of-life-care (QEOLC), andpatient depressive symptoms. Ultimately, this intervention wasnot associated with a significant change in either QOC orQEOLC in either the patient or family groups. The interven-tion was associated with a small but statistically significant in-crease in depression scores among patients of the interventiongroup. There were some substantial limitations to this study.There were overall low response rates (44% of patients) andsignificantly lower rates for patients in hospice care, thosewith documented end-of-life care discussion, those > 80 yearsold, those with cancer, and family members of patients whodied; groups that arguably would have had substantial benefitfrom these discussions with their physicians. The authors alsoraise the issue of difficulties of untrained patients being able toaccurately and objectively rate clinician communication.Lastly, the evaluation period lasted 10 months, potentiallyintroducing recall bias as a confounder and missed shorter-term benefits.

[Avery MacKenzie, MD

Denver Health Medical Center, Denver, CO]

Comments: Communicating with critically ill patients in anhonest, concise, and straightforward manner is an importantskill for emergency physicians. However, this research doesnot support implementation of costly and time-consuming,simulation-based workshops to improve these skills in trainees.More research will likely need to be done to identify interven-tions that may improve provider proficiency in this importantrealm of patient care.

, COST-EFFECTIVENESS OF LOW-MOLECULAR-WEIGHT HEPARIN COMPARED WITH ASPIRIN FORPROPHYLAXIS AGAINST VENOUS THROMBOEM-BOLISM AFTER TOTAL JOINT ARTHROPLASTY.Schousboe J, Brown G. J Bone Joint Surg Am 2013; 95:1256–64.

There is a high rate of venous thromboembolic (VTE) dis-ease in patients undergoing total hip or knee replacements,and there is controversy over which prophylactic anticoagulantis appropriate for this high-risk population. The authors soughtto compare VTE prophylaxis with 14 days of oral aspirin vs. 14days of low-molecular-weight heparin (LMWH) with respect tolifetime costs, gained quality-adjusted life years (QALYs) andcost per QALY by using a Markov cohort of patients withouthistory of VTE that underwent either total hip arthroplasty(THA) or total knee arthroplasty (TKA). Using these data, theauthors performed a probability sensitivity analysis and founda decreased probability of LMWH being cost effective forpatients undergoing THA and for those 80 years old or higherundergoing TKA. The authors conclude that in patients under-going THAwithout a history of VTE, aspirin is adequate VTEprophylaxis, but in similar patients undergoing TKA, the antico-agulant of choice is age dependent and still unclear.

[Joseph Hemerka, MD

Denver Health Medical Center, Denver, CO]

Comments: Emergency departments commonly see patientswith VTE disease after undergoing THA or TKA. This study didnot directly address the efficacy of aspirin vs. LMWH in VTEprevention, so it should not be used to change our diagnosticdecision-making in these patients. Additionally, there is adisclosure made that one or more authors had a financial rela-tionship that could be considered a bias. Overall, althoughboth aspirin and LWMH are used in VTE prophylaxis, it seemsthat aspirin may be an overall cost-effective alternative in pa-tients without a history of VTE undergoing THA and in youngerpatients undergoing TKA.

, A RANDOMIZED TRIAL OF NIGHTTIME PHYSI-CIAN STAFFING IN AN INTENSIVE CARE UNIT. KerlinMP, Small DS, Cooney E, et al. N Engl J Med 2013; 368:2201–9.

Intensive care units (ICUs) are increasingly seeking 24-hattending intensivist coverage. Although intuitively it wouldseem that increased attending coverage would improve patientoutcomes, this has yet to be studied. To study this effect, the au-thors at a single academic medical ICU conducted a 1-year ran-domized study in which attending intensivists were scheduled towork a block of seven consecutive overnight shifts (to encom-pass 24-h coverage) vs. standard staffing (resident coveragewith attending/fellow available by telephone). The primaryoutcome was length of stay in the ICU, for which there wasno significant difference between groups (rate ratio for ICUdischarge, 0.98; 95% confidence interval 0.88–1.09). Secondaryoutcomes included total hospital stay, ICU and in-hospital mor-tality, discharge to home from hospital, and ICU readmissions(within 48 h), all of which did not have significant changes.